Heritage Specialty Care: Call Light Failure Leaves Resident - IA
Nobody came.
He had been incontinent of both bowel and bladder. The call light, which staff were supposed to keep within his reach at all times, had been placed by the night shift aide on top of the call light box mounted to the wall, out of his reach entirely. He could not get to it. He could not summon help. He lay there and waited.
This is what federal inspectors documented when they investigated a complaint at Heritage Specialty Care, a 118-bed nursing facility at 200 Clive Drive SW in Cedar Rapids. The inspection was completed August 26, 2025.
The resident, identified in inspection records only as Resident 3, had no memory impairment. He knew exactly what had happened to him and why he couldn't get help. He knew who had failed him. He just couldn't remember the name of the aide.
His care plan had flagged him as a fall risk since October 2024. It directed staff to encourage him to use his call light and to make sure it was within reach. That instruction existed precisely because of his physical condition, because of what a stroke and hemiplegia had taken from him, because there were things he simply could not do for himself without that one piece of equipment working the way it was supposed to.
On the morning of July 30, 2025, it wasn't.
Staff B, a certified nursing assistant who had worked at Heritage Specialty Care since February of that year, was coming on for the day shift, which ran from 6 a.m. to 2 p.m. Normally, she said, day shift staff did a room-to-room handoff with the night shift, walking through each resident's room together. That morning, they didn't do it. She came in through the front door and walked down the hall toward the nurses' station.
That's when she heard him.
He was rattling the bed rail and calling out. She recognized immediately what it meant. "That was what he did if he dropped his call light or cannot get to it," she told inspectors. She went to his room. She found him incontinent of bowel and bladder. She asked him what was going on, because he was normally continent.
He told her that someone had put him to bed and taken his call light. She looked at the wall. The call light was sitting on top of the call light box, mounted to the wall, out of his reach.
She provided care, helped transfer him to his chair, and asked the assistant director of nursing to come speak with him.
The facility's own incident report, filed the same day, confirmed what the resident said: the third-shift aide had failed to provide assistance when he was incontinent, and he could not call for help because the call light was out of reach. The resident reported the night shift aide had been in his room earlier, had placed the call light on the wall box, and had not returned.
When the director of nursing spoke with inspectors on August 20, she offered an explanation for how the call light ended up on the wall. The resident was independent in his room, she said, and at times staff moved the call light out of his way so he didn't roll over it. That morning, she acknowledged, the night shift aide had placed it on the box on the wall.
The gap between those two things, between moving a call light so a resident doesn't roll over it and placing it on a wall mount where a man with hemiplegia cannot reach it, is exactly the gap that left him lying in his own waste until a day shift CNA happened to walk past and hear him shaking the rail.
The facility's response was to re-educate staff. The director of nursing told inspectors they focused the re-education on what constitutes abuse and on customer service.
By the time inspectors interviewed the resident himself, on August 18, he said the incident had occurred one time. He had no memory of which staff member had been involved. He reported no further concerns.
That last detail is worth sitting with. A man with no memory impairment, clear enough about what happened to file a complaint, clear enough to tell the morning CNA that someone had put him to bed and taken his call light, interviewed nearly three weeks later, said he had no further concerns. What he did not say, and what the record does not show, is that anything had changed in a structural way to prevent the same thing from happening again.
The facility's own policy on activities of daily living, last revised in March 2018, states that residents will be provided with care and services to ensure their ADLs do not diminish, and that appropriate support will be provided for residents who cannot carry out ADLs independently, including assistance with elimination. The call light is not incidental to that policy. For a resident with hemiplegia and a documented fall risk, it is the mechanism through which he asks for the help the policy promises him.
When it ends up on a wall box out of his reach at the end of a night shift, the policy means nothing.
What the inspection report does not say is whether anyone on the night shift was disciplined, whether the aide who placed the call light on the wall box was identified, or whether the facility's re-education sessions covered the specific mechanics of how a call light ends up inaccessible to a resident who needs it. It does not say whether the room-to-room handoff that was skipped that morning was skipped routinely or only that once. It does not say what would have happened if Staff B had taken a different route to the nurses' station.
He had survived a stroke. He had learned to live with hemiplegia. He had a care plan that acknowledged his limitations and spelled out what staff were supposed to do to keep him safe. On the night of July 29 into the morning of July 30, none of that mattered, because the person responsible for his overnight care put his call light somewhere he couldn't reach it and left.
He rattled the bed rail. He called out into the hallway. He waited.
Eventually, someone heard him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Specialty Care from 2025-08-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Heritage Specialty Care in Cedar Rapids, IA was cited for violations during a health inspection on August 26, 2025.
He had been incontinent of both bowel and bladder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.